When I finished my SIBO treatment last month, I was convinced I still had critters.

Even though I had been taking herbal antibiotics for nearly 6 weeks, my system still felt off. My stomach continued to bulge, my digestion was pokey. I was burping during meals, no matter how many FODMAP’s were on my plate. And despite these symptoms (which I laid out in Part 1 of this series) having gotten a little better, their persistence seemed to be evidence that whatever hodgepodge approach I had taken to ridding my small intestine of its bacterial burden, had failed.

This SIBO-style paranoia seems to be common among sufferers I’ve spoken to. And for good reason. The first being that treatment options are complicated, varied, and often take doctors a few tries to tailor to the individual. The second being that even if one works the first time, SIBO is a chronic condition that often relapses within 3 weeks of finishing treatment.

In case that thoroughly bummed you out, I’ll share with you the little piece of news that I received this week that put a pin in my SIBO stress balloon (and, the one slowly deflating in my abdomen): after two months in the weeds, I’m officially SIBO free!

I’ve included a screenshot below of my two tests side by side in case you’re curious. If you’re wondering how to read them or how it works, make sure to brush up on SIBO 101 in this post.

As I waited for the results, which came 3 weeks after I finished my course of herbal antibiotics (the Biotics protocol discussed below), I planned for the worst and continued to diligently research other treatment options, debate which route I would try for the next round, and question whether I would ever end up desperate enough to get my meals in the form of a medical liquid (i.e. the elemental diet).

Today’s post is a result of that deep dive. In it I lay out the three main phases of SIBO treatment, the three primary approaches to killing your bacteria, and the many many herbal supplements and lifestyle changes that are recommended to treat symptoms and aid in the process.

One prong of the treatment plan that’s not discussed as often is optimism. I can’t stress enough how bad stress is for any chronic condition, even though chronic health conditions are some of the most stressful life forces on the planet.

As hard as it may seem, try to stay positive.

My guiding light throughout this process was knowing that my experience with SIBO could help others navigate it down the line. And you don’t have to be a blogger with a platform to embrace that silver lining. I got some wonderful emails from friends who took meticulous notes (and created fabulous spreadsheets) during their year-long battles with SIBO.

Remember that dealing with SIBO is a wellness project in and of itself. Embrace the trial and error. And even if the road feels long, once you take the scenic route up Health Mountain, you’ll be that much better equipped to guide others on the journeys that lie ahead.

Though doctors are becoming savvier about testing for SIBO, they often focus on just the kill phase and don’t always appreciate the full breadth of what it takes to eradicate it for good.

Here is how I break down the timeline:

1. The Kill Phase (2 – 6 weeks)

This phase lasts as long as the medication protocol prescribed, most commonly a generic antibiotic like Rifaximin or one of the herbal protocols. There’s a debate as to whether a low FODMAP diet is beneficial during the kill phase, which I will discuss briefly at the end of this post. For those with severe symptoms, beginning a low FODMAP protocol will help jump start the healing phase and provide some relief, but you don’t want to be so strict that the bacteria go into hibernation because they’ve fully lost their food source.

2. The Healing Phase (2 – 3 months)

It’s recommended that you retest for SIBO exactly two weeks after the antibiotic protocol is complete. Some people who are feeling better will continue onto the next phase regardless since the test is expensive. Others will wait until a negative result is achieved, and then proceed with some diet modifications that aim to heal the intestinal lining and rebuild the immune system, usually the slow reintroduction of high FODMAP foods, coupled with the GAPS diet.

3. The Recovery Phase (On-Going)

SIBO is a chronic condition. If it comes back, it’s not an indication that the treatment plan didn’t work, but rather, that the root cause hasn’t been dealt with properly on an on-going basis. This is where a lot of the lifestyle modifications come into play, and in some cases, where it’s necessary to continue certain supplements, specifically the ones that improve motility (i.e. those that make sure you’re pooping properly).

Today’s post will mostly focus on the kill phase, though some of the lifestyle recommendations pertain to phase 2 and 3, which will be discussed in the last part of this series.

THE BEST ANTIBIOTICS AND HERBAL TREATMENTS FOR SIBO

The options for treating SIBO during the Kill Phase fall into three categories: regular antibiotics, herbal antibiotics, and The Elemental Diet. With the exception of the latter, which is full package approach, there are still plenty of dietary and lifestyle changes, and additional supplements, that will help the medication do its job. I’ll get to those later. For now, let’s talk about the pro’s and con’s of natural treatments versus the pharma route.

The first thing that your physician should keep in mind is that the treatment for SIBO is different depending on whether it is methane or hydrogen producing, and presenting symptoms as constipation (SIBO-C) or diarrhea (SIBO-D). There is usually a strong correlation with these symptoms and which gas is present (methane-C, hydrogen-D), but not always. Make sure to discuss both with your doctor to ensure you choose the right protocol.

1. Antibiotics (2 weeks)

There are several pharmaceutical antibiotics which are commonly prescribed for SIBO: Neomycin (better for Methane dominant), Metronidazole, and Rifaximin. The benefits of antibiotics top out after 3 weeks, so a 2 week course is the sweet spot.

Rifaximin (generic: Xifaxan) has the best reputation of the group, even among naturopaths, as it’s an antibiotic with “eubiotic effects.” It specifically targets the area we need to eradicate—only killing bacteria in small intestine. According to studies, the side effects are mild and the die-off of beneficial species of bacteria in the colon is minimal. For those who are wary of antibiotics, this isn’t a bad one.

However, the main problem with Rifaximin (and all other pharma options in this category) is that with repeat use, you increase the likelihood of becoming resistant. Meaning, it might be worth one try, but you don’t want to get into a cycle of use, especially when there are other natural options that have been proven equally effective with fewer long-term risks.

2. Herbal Antibiotics (4 – 6 weeks)

People don’t necessarily gravitate towards herbal options just because they’re more “natural.” Rather, certain combinations of herbal antibiotics have been proven in studies to be just as effective, if not more effective than their pharma counterparts.

The downside: more pills, for longer, with the possibility of GI side effects. Just because herbs are natural doesn’t mean they’ll be tolerated by everyone. I certainly experienced discomfort and an increase in my constipation symptoms while on the Biotics formula.

The upside? You can purchase these herbs without a prescription and experiment on your own. Which, considering you can now take a SIBO test at home, is an affordable option for those who aren’t able to invest in the helping hand of an integrative doctor.

So what are the best protocols for herbal antibiotics? The two most commonly used herbal blends in Dr. Alison Siebecker’s practice, who is commonly thought of as the pioneer of SIBO, are:

Typical dosing is: 2 caps, twice a day, for 4 weeks. For what it’s worth, I did the Biotics system for 6 weeks.

The two protocols above combine several individual herbs that are thought to be helpful, including berberine herbs, ginger and oregano. There’s definitely a big pro to having a formula already sussed out for you. But another route is to design your own treatment using a combination of the below herbs. Dr. Allison Siebecker recommends 1-3 in combination, for 4 weeks, at highest dose suggested on product labels.

Allicin: Though it’s derived from garlic, this strong antimicrobial doesn’t contain the FODMAP’s found in other parts of the clove. The highest potency formula is Allimed. This is the only single use herb that’s been studied with SIBO, and was found to be effective for methane-dominant SIBO. It can be added to one of the above protocols, or used in conjunction with Berberine and Neem.

Berberine Complex: these herbs are also found in the Metagenics formula. It’s derived from Goldenseal, Oregon Grape, Barberry, and other herbs. Many use this in conjunction with oil of oregano and neem for hydrogen-dominant SIBO.

Neem Plus: Neem is a tropical evergreen tree and is said to enhance the positive effects of the two herbs above.

Oil of Oregano: This herb has been known as a longtime antifungal, antimicrobial, antiviral powerhouse. During my Biotics protocol, I habitually added two drops to my water or took a veggie capsule of it with my other pills.

3. The Elemental Diet (2 weeks)

If all else fails, there’s always the elemental diet. It is thought of as a last resort because of the extreme unfun-ness of the protocol, which involves drinking a medical solution for all meals for a 14 day period. I can’t imagine ever doing this, but it’s a relatively quick strategy that’s proven 85 percent effective at starving out the bacteria, while, on a purely elemental level, feeding the person.

The mixture includes liquid nutrients in an easily assimilated form that is used in hospitals on GI patients whose system needs to heal. The nutrients get absorbed quickly and easily in the first leg of the digestive labyrinth, meaning they never make it to the area of the small intestines where unwanted bacteria congregates in SIBO patients.

The protocol is suggested for 14 days, with a retest taking place on the 15th day. Overnight results should be requested so that you can immediately start the diet for an additional week if there’s still a positive.

Again, this is if all other protocols fail. It’s not recommended to take antibiotics or herbs during the elemental diet because the bacteria, without food sources, will essentially be hibernating or die off on their own, as intended by the diet.

As you may remember from lesson 1, one of the biggest underlying problems that contributes to SIBO is a screwy, slowed Migrating Motor Complex (MMC). Luckily, there are several easy changes you can make to your diet to help your digestive system catch up. We will talk about these more in the next installment.

Add lemon juice to your water before meals to get your stomach acid flowing. This will help prevent more bacteria from making its way into the small intestines and aid in digestion.

Sometimes the MMC can’t be stimulated properly through diet alone, which is where prescription medication and additional supplements come in. This list may seem overwhelming, so remember that this is not an “all of the above” suggestion. Rather, some of these supplements can be used as added strategies down the line or to treat discomfort throughout the process as needed.

Digestive Enzymes: Bacteria could be becoming trapped in the small intestines for a few reasons. But the problem escalates when said bacteria are being fed all too well. While you can employ some of the good habits mentioned above, a strong digestive enzyme taken at each meal will help break down food so that it assimilates prior to reaching the bacteria. I took 2 Digestzyme- capsules with lunch and dinner (I skipped breakfast).

Prescription Prokinetics: These pills, which stimulate the MMC, are an essential part of prevention and on-going support after you’ve finished a course of treatment. Many doctors will advise waiting until after the kill phase/antibiotic protocol to start a prokinetic. This is likely because you don’t want the antibiotics to be moving through your system too fast – the pills need time in your small intestines to do their job! So you’re better off choosing from some of the natural suggestions below and then switching to one of these prescriptions after your first course of treatment if you’re still feeling backed up. Low Dose Naltrexone and Low-dose Erythromycin are the most common. You can find dosing advice here but keep in mind your doctor will have to advise.

Non-Prescription Motility Supplements/Prokinetics: These herbal formulas help keep things moving without the need for a prescription, and are also used in conjunction with antibiotic treatment, especially if you’re experiencing constipation from the medication. Start with one strategy and layer as needed.

Motilpro – Made from ginger and quite potent. Take 3 caps before bed and 2 caps between meals.

Traphala – This is essentially a mild Ayurvedic laxative. My doctor didn’t recommend it, but I’ve found traphala herbs to be a gentle helping hand when I’m feeling backed up. Try one capsule before bed. Another Indian trick is to add a pea-sized amount of ghee or coconut oil to your belly button before bed. It’s said to literally lubricate your digestive tract. I will cover with a bandaid so that it doesn’t ruin my shirt as it melts.

Smooth Move Tea – This tea has been my last resort laxative ever since I was a child. Half a cup before bed is enough to make me explode. For those who doubt the medicinal potency of herbs, just give them this tea! I drank this a few times during my treatment when I was feeling particularly backed up.

Psyllium Husk – A prebiotic fiber, the powder from this seed helps cleanse the colon and produce more even, predictable poops. It’s been studied as a positive supplement in treating IBS symptoms. Though I haven’t experimented myself, I wanted to add as an option. 1 cap before bed.

Natural Calm – This product is made of magnesium and calcium. It’s marketed for stress and a good night’s sleep (two bonuses) but can also help keep you regular if you add a tablespoon or two to your water before bed. I like the fizzy, tart taste and the gentle effect it has on my insides.

Supplements for Reducing SIBO Symptoms: As I shared from my experience, symptoms of bloating, gas, and GI distress don’t go away overnight, and can sometimes be exacerbated by the “kill treatments.” If diet alone doesn’t help alleviate, one or more of these supplements can be added to your regimen.

Enteric Coated Peppermint Oil: a drop or two of the essential oil in a glass of water prior to a meal can help reduce bloating and gas, as well as other symptoms of digestive upset, or you can take a capsule.

Supplements to Breaking-Up Biofilm: These pills are added value for your kill treatments as they help breakdown the cell walls of bacteria (biofilm) and allow antibiotics to access their intended target. I took 2 capsules of Interfase by Klaire Labs between meals when I could remember. It’s unclear though whether it was necessary.

Visceral Mobilization: This strategy for removing blockages to the small intestine isn’t discussed enough. It’s essentially a targeting intestinal massage and you can try to find a practitioner in your area who is trained in VM. Here’s a great article explaining it and offering advice for how to give belly a self massage to help it operate properly.

DO PREBIOTICS OR PROBIOTICS WORK FOR SIBO?

Most people who talk about SIBO treatments take the starve and kill strategy: switch to a diet that’s low in foods your bacteria like to eat (fermentable carbohydrates) to try to reduce them, and add in a medication that will further the extermination. Usually this involves a combination of the low FODMAP Diet and the Specific Carb Diet, and also means eliminating fermented, probiotic foods, and inulin-rich prebiotic foods that have long been touted as a healthy gut’s best friend.

There is another school of thought, however.

And that is to use probiotic and prebiotic supplements as a means of righting your overall bacterial imbalance.

The research is much more sparse for this line of treatment, but there have been several small studies that indicate using probiotics doesn’t hurt, and its ability to help is strain specific.

The argument for probiotics, as Dr Jason Hawrelak explained in his lecture on the subject, is that they can speed transit time, stimulate the MMC, help heal leaky gut by regrowing villi, and ease gut hypersensitivity which is common with SIBO.

I don’t bring this up to confuse you, though of course offering up a mode of treatment that is in direct conflict with the ones I just mentioned above, does seem downright confusing! The point is that every body is different. There are many solutions and ways to tackle the problem of SIBO, and there’s not a single approach yet that has been proven to be “right.”

If adding rather than taking away seems like a better approach, you can do more research on probiotics and SIBO, and/or experiment with prebiotics like Allicin, Partially Hydrolyzed Guar Gum, and GOS’s.

As Dr Jason Hawrelak argues, SIBO sufferers react to high FODMAP foods because there’s something wrong with their gut not because the FODMAPs are harmful. And using probiotics to shift the bacterial ecosystem usually means an overall smaller population of bacteria in the small intestine.

The low FODMAP and SCD diets target carbs because that’s what bacteria like. They are also a great tool for reducing symptoms and giving patients a sense of control. But the ultimate outcome you want is to be able to eat all the beneficial vegetables and treat the underlying cause to get you there.

And that dietary part of the debate–both what to do during treatment and afterwards to prevent relapse–is where we are going to pick up next time!

I recently added a low FODMAP track to my online course, 4 Weeks to Wellness. You’ll now receive a 20 recipe cookbook, shopping lists, elimination diet guidance and reintroduction worksheets, in addition to the many other resources in the normal program.

Disclaimer: this website offers health, wellness, and nutritional information for educational purposes only. Information provided is not intended as a substitute for the advice provided by your physician or other healthcare professional. Always speak with your physician before trying any new treatment.

Reader Interactions

Comments

I don’t suffer from SIBO but occasional constipation. I used to use some of your remedies such as senna teas (Smooth Move is one of them) but have come to favor Aerobic Life Mag 07 Digestive System Cleanser, 1-2 caps at bedtime for two or three days. It’s magnesium, which is the laxative part, with the addition of the extra-oxygen molecule, and extra oxygen is anathema to bacteria. The purge is very gentle and, over several days, quite thorough. No skid marks.

Congrats again! Ugh, I can’t wait to declare the same thing. Scheduled for Endoscopy/Colonoscopy (just finished Rifaximin for the third time) whiiich my GI doesn’t think will be conclusive- hooray! Going to try your method, just bought the Biotics…crossing my fingers! Had you considered Atrantil at all? Another one I wish there were more tests on!

Ah Shawna, hang in there girl! I actually had a friend who recommended Atrantil. You can take it without changing your diet, which is great. Apparently helps the bloating too. If you try it report back! I’m considering adding to the options above, but like you I wish i knew more!

I have SIBO and find your articles very informative. I am about to start the Biotics protocol but not sure if I should take them with meals. Did you take them with food or on an empty stomach ? Thanks ahead for your help.

Hi Phoebe, thanks for your response. I am almost done with the six week Biotics treatment and I feel great ! This is the first time in two years that I actually feel like myself again. I am so glad I find your website. Quick question, do you suggest taking probiotics after the treatment ? My doctor suggested it but I read opposite opinions online.

so glad you are feeling good! yes, once you confirm that SIBO test comes back negative, then begin your healing phase, which can include slowly reincorporating fermented foods and taking a robust probiotic. At least, that’s what i did!

Hi, I was recently diagnosed with SIBO by my doctor and was told to go low FODMAP for 2 months and they we would rerun my blood work. He didn’t do the breathe test but all my symptoms and issues point in that direction. Do you think I should wait the 2 months to reassess with my doctor or try the herbal supplements? Now that I’m learning about the “kill phase” and all of the specifics of the diet it feels like a waiting game. My doctor is not a specialist by any means, he’s just an internal medicine doctor that actually listens to my complaints and looks for solutions.

hi jami! if you weren’t tested, it’s not really a diagnosis, just a suspicion. Some people feel better just going low FODMAP for a little while. But if you have SIBO, and a bad case, then it’s probably not going to eradicate it on its own. The diet lessons symptoms but doesn’t clear the bacteria. I would recommend getting tested so you can see exactly what you’re dealing with (methane vs hydrogen dominant) and choose the best herbal or conventional protocol to deal with the beast you’ve got. You can definitely go low FODMAP tomorrow though to help your symptoms!

Hi Phoebe! I’m so happy that I found your blog, I’ve been all over the internet (I’m sure like anyone with a SIBO diagnosis) and I just get SO discouraged. And nobody had any solutions to help constipation during the kill phase ahhh! I find that if I’m reallt constipated it affects my mental health so much! Anyways thank you so much for you words, they are clear and conscious and easy to understand!! I’m on my second treatment of herbals (nobody can figure out my root cause) and added Neem and took out probiotics. I’m struggling right now but eager to try some of those symptom relievers and constipation one’s as well. Last time I stuck with the lowfodnap diet so symptoms weren’t as bad… but I think I needed the bacteria to be more present. We will see. Congrats on your cleaner gut haha!

Hi Phoebe. I’ve been trying to get my SIBO C under control for four years. The protocols make me worse so I’ve always given up after a few days. How long did your C worsen for on your successful go? I need to know from someone who’s been through it!

I have been dealing with these symptoms for about 20 years . I have just been confirmed after 4 years of testing that I have sibo. Iv had at least 6 rounds of antibiotics in the last few years recently for 28 days straight . In that process was rushed to the hospital numerous times due to dehydration and what they thought was a stroke or heart condition but all test came back normal which led them to blame the sibo. What do you recommend

I’m not a doctor. My recommendations are many and they are housed in the three posts on the subject. There are a lot of different options depending on whether you are Hydrogen or Methane and what your symptoms are.

I’m curious if anyone else has had the same experience with SIBO as me…. I accidentally discovered I had it after taking a round of Augmentin when I had a sinus infection and my symptoms resolved (hair loss stopped a few months later and digestive issues stopped almost immediately). However, since then, my digestive symptoms have not really returned but my hair loss has continued for YEARS. Is it possible to have subclinical SIBO where I still have some symptoms but my digestive symptoms are not present.

I’m not a doctor, but when I hear hair loss, I usually think of autoimmune issues….many of which are risk factors for SIBO. I would have your thyroid checked and rule out Hashimoto’s along with some other things that could be causing the hair loss. And feeding your gut with probiotic-rich foods can’t hurt!

Thanks for responding Phoebe. I actually do have Hashiomoto’s thyroiditis but have been on thyroid medication for more than a decade and continue to get my levels checked regularly. Despite the normal T3 and T4 levels, I still have had hair loss for almost 4 years. Twice the hair loss stopped for a few months and both times I had taken antibiotics about 3 months prior. Do you know of any autoimmune reason why the antibiotics would have resolved my hair loss temporarily?

Thank you so much for sharing your experience. I’ve been unable to eat a single thing without looking like I’m full term for almost a year now. I was really happy to find your blog and know that I’m not alone in this!! I was wondering if for the two Biotics pills you took, you alternated between the two or if you just took them at the same time. Were you working with a functional medicine doctor or were you able to beat this on your own? Thanks for mentioning different options well. This was super informative! And congrats on beating the beast!

Glad to hear it’s helpful H. It’s 2 of both pills, twice a day. I worked with a functional medicine doctor and he was very helpful but I also did a lot of my own research. If you’re in NYC, check out my list of holistic practitioners. If not, there’s a wonderful MD Alison Siebecker who has an online program: https://bit.ly/2PxKayg

I only needed one treatment, so no resistance. If I ever have to treat again I might rotate to something else just to hedge my bets. But knocking on wood that the occasion doesn’t arise for quite a while!

Thank you so much for sharing! This is life changing for me since I cannot find a doctor who will even talk to me about Sibo. I have a question regarding dosage. Should one take the Biotics, Prokinetics, Iberogast, and Interfase at the same time? Meaning… all in one day. Or, are the Prokinetics for after the 6 week treatment?

Thank you so much for sharing! This is life changing for me since I cannot find a doctor who will even talk to me about Sibo. I have a question regarding dosage. Should one take the Biotics, Prokinetics, Iberogast, Motilpro and Interfase at the same time? Meaning… all in one day. Or, are the Prokinetics for after the 6 week treatment?

The prokinetics are usually for after first treatment, though I think if you require a second round, the doctors I’ve spoken with recommend continuing the prokinetic you’ve started. I would just choose one or two and see if they help. You don’t want to overload your system with pills!

Hi Phoebe, I think I have some sort of SIBO with quite important reactions to garlic and inulin. You mention allicin does not contain any FODMAP (i.e. inulin, a prebiotic fiber). Yet, you then cite allicin as potential prebiotic. Are you sure about that? Which fiber would it contain if not inulin? Also, funny you mentionned Triphala as a laxative… Throughout my “research”, it seems that a lot of laxatives are also prebiotic fibers..Made a quick check and seems to be the case for Triphala! I’ll add it to my collection of prebiotics.(also antibacterial btw..)

Hi Phoebe! I am glad to have stumbled upon your page. I am a little over halfway through a 14-day round of Rifaximin, and I haven’t felt all that much better yet. I also have been eating a mixture of low and fodmaps. I’m worried that this means the treatment isn’t working – could this be the case or is it normal to still feel bloated/crampy/etc during the killing phase? Thanks again. I have definitely become a bit neurotic over the past few months.

Try not to stress! It makes symptoms worse and healing harder 🙂 I didn’t do the rifaximin, so can’t speak to that, but I didn’t feel better until after my treatment. Any antimicrobial is hard on the body, and you could be experiencing symptoms of “die-off.” I need to write a post just about that!

Hi Phoebe, I will start the Kill Phase this week with Metagenics Candibactin-AR + Candibactin-BR. I also bought GutPro – Probiotics Capsules. Should I wait with the Probiotics until the end of the Kill Phase ? Thank you Yoav

A few years ago I was diagnosed with M.E / Chronic Fatigue Syndrome. I believe I have had this condition for over 30 years in varying degrees but about 18 months ago I was heading towards the “crash stage”. I found a very good clinic which specialised in M.E / CFS who approached this from two angles, Physiological and Psychological. Since then I have had various tests which have highlighted a number of issues including infections, bacteria, low adrenals, high mycotoxin levels and poor liver functionality, to name a few. As a result I have been on a number of supplements over the last 18 months and although I was improving I recently reached a plateau and was not progressing any further. My nutritionist suggested taking a SIBO breath test (lactulose) which subsequently showed high levels of both Hydrogen and Methane. I have recently started an antimicrobial protocol with A.D.P oregano (Biotics) and Allicin Max. I am taking one capsule of each at meal times whilst incorporating a low FODMAP diet. I am also taking a Digestzyme capsule before meals and 20 drops of Iberogast with each meal and 60 drops at bedtime. The only other supplement I am taking is a Liver GI capsule twice daily. I have to follow this protocol for 6 weeks, have 1-2 weeks off and then have a second round. I am almost 3 weeks into this and am feeling awful at the moment with very low energy levels and my immune system at a low ebb. I would be interested to hear if you have heard of any other M.E / CFS sufferers who have been diagnosed with SIBO and any helpful thoughts or advice you may have? P.S. Keep up the good work on your webpage as it is interesting and written in a way that makes it easy to understand the complex issues around this condition.

I had the same problem, fatigue, and I was diagnosed (using breath test) with SIBO (after 10 months of misery). There is a MD/professor in New York (forgot his name) who found the link between SIBO and Fatigue, and presented it in a conference, and I stumbled online on the abstract of his work. I took antibiotic Xifaxan for 10 days and felt noticeably improved. But I knew I needed to treat the root cause of SIBO in order to prevent SIBO from relapsing. Cause is not certain, so was not treated, so SIBO fatigue relapsed. I couldn’t afford Xifaxan again (i had used a manufacturer’s discount coupon the first time and bought medication for $10— but coupon not available anymore, and Xifaxan cost $600, no generic available, and insurance does not cover it if your doctor writes diagnosis as fatigue or SIBO, but will cover it your Doctor writes traveller’s diarrhea).. For me, the SIBO seems to cause leaky gut downstream, which compounds the fatigue. The link between the two is production of lecithin in small intestine (impaired by SIBO) within the mucus, which coats the gut, forming a component of the gut-blood barrier. I controlled leaky gut with lecithin enema (after bowel movement), or oral lecithin+Alli, and one time with Protectyn (pricey at sufficient dose). Certainly, the more upstream you treat the problem, the better. I think the cause of my SIBO is lack of MMC. I am going to confirm/exclude that by trying the Iberogast you described + ginger (or ProMotilin) and see..

Interesting to note that you knew you needed to treat the root cause of SIBO but I guess that is a difficult thing to do. Having read various articles I feel that my root cause was linked to taking PPI’s on maximum dosage for over 5 years.

In February this year I managed to get a prescription for Rifaximin following a consultation with a Gastroenterologist. Following this I took another SIBO breath test which showed a marked decrease in Hydrogen and Methane levels.

I am now following a new supplement protocol which includes adrenal and magnesium supplements and in the last week I feel that my energy levels are very slowly increasing.

I’ve been sick for 6 months, after many test they said I have Sibo, I’ve asked for the result numbers several times and still waiting for them, I was just told I tested positive. I was put on flagyl and I only made it 12 days , I was so sick I couldn’t take another pill. I suggest Xifaxan to the doctor after reading info online, it looked like the more high success rate, my doctor said ok but most insurance don’t cover them or need a pre- authorization , my insurance did cover them. Now I’m on Xifaxan, today is day 10, the meds aren’t making me sick like the other did, but I’m still sick, I’m sick after eating all the time, I’m trying to eat good for the most part, banana for breakfast, salad or chicken for lunch, rice and chicken for dinner or fish, not to much else, maybe a decaf tea sometimes. I’m so tired of being sick , I have discomfort on the left side of my stomach and intergestion or sick feeling in my Esophagus, I even have tension in my neck on the left side , could be stress related, I guess , I’ve had extremely anxiety since all this started, my doctor has put me on meds for it because I was falling apart. My doctor wants to follow up with me in 6 weeks, this was the first opening, so if this hasn’t worked, i guess I’ll know soon, I have to wait 6 weeks to see him ???? I’m sick hello !! I’m done waiting for anything, I’m considering getting a second opinion in Boston, I’m on the right track I guess but I’m still sick and confused what to do next. I’m going to work sick all the time, not pleasant. I have some good days but more bad, if the meds didn’t work, should I try the natural stuff after I’m done the Xifaxan? I’m getting desperate enough to try the liquid diet for 14 days, whatever it takes. Any suggestions would be appreciated, thank you for all the information you’re putting out here, I felt helpless to a point and your info has given me some hope, I’ve been read as much about sibo online as I can, and I’m wondering if I now know more about sibo than the GI MD.

Hi, I was wondering with the biotics that you took I know you said 2 pills twice a day. Did you mean 2 of each pill twice a day ( so 8 pills total a day( or one of each pill twice a day(so 4 pills total a day)?

Hello Phoebe, What na amazing source on Sibo you have created here. Just what i was looking for. I was on ADP Biotics and Berberine as per functional doc recommendation but i do not think it did me any good.I feel even worse a year after treatment. I presume i had methane sibo as i was constipated all the time..Organic Acid Test just indicated bacterial overgrowth. I do not spend my money on private vists to functional medicine doctor anymore and started looking for another treatment option myself and found all you wonderfull Articles. One thing i wanted to ask was whether you considered coffee enemas during sibo treatment…or even afterwards?It was one good advise i managed to stick to as at the moment i do not have to use laxatives to help with regularity….many thanks for all your advice which i am going to useand my best wishes to you. Monika

Hello Phoebe, I am suffering from constipation, bloating. There is no SIBO test in my country. Based on my research, I suspect that I have methane dominant SIBO. I ordered Dysbiocide, I use it for 10 days but I dont see any change. Did you experience hydrogen-vs-methane SIBO? Is Dysbiocide used for hydrogen or methane SIBO? I am not looking for medical advice but I really need information. As I said, there is no test for SIBO in my country.

I am commenting because i like the way your site flows and is well written. I have been suffering for 10 years from everyday bloating and fatigue I have hasimotos. I have had breath tests at the docs office that most times have been positive. And sometimes spike pretty early. I stopped taking the tests and assume I still have SIBO. Your explanations make sense to me. I really struggle with SIBO diet. But I don’t eat horrible. I get sugar cravings tho for gummi bears. I just stumbled across Flagyl last week as I was taking it for something else and while I was on it i had relief from everything including reflux. Started culturelle this week after the antibiotics to colonize my gut. Had bloating issues in the past starting probiotics and quit. I spent $$ on these and even with the discomfort that has not subsided I am going to keep taking them. I have no idea if SIBO is back or what or it is just the probiotics. Reflux is back too. Not sure what to do along with the probiotics. Thanks

Hi, Phoebe! Thank you for the great info! I am currently treating SIBO with the Biotics protocol along with Allicin. It was hard to find information on the SIBO-C herbal treatment. I have just been taking 2 caps of Allicin twice a day with the Dysbiocide and FC Cidal (10 pills a day total). Do you happen to know if the Biotics and Allicin is sufficient for SIBO-C? Thank you for your time 🙂

I have had IBS-Constipation for over 20 years, and I was just diagnosed with methane-dominant SIBO through the breath test. High levels of methane slow motility, so the SIBO seems to be a contributor to the constipation. Today I’m beginning the Rifaxamin + Neomycin one-two punch combo that has been show most effective for methane SIBO. Please send good vibes!!!

There is no clear post-kill path, however. It’s clear I’ll need some kind of pro-kinetic/pro-motility agent – the doctor is encouraging me to take Linzess for the constipation, but I’m very concerned about all of the side effects and explosive diarrhea people experience on it. HAS ANYONE WITH IBS-C AND/OR SIBO-METHANE USED LINZESS? I’ll also need to change my diet to move away from most of the healthy things I love to eat, at least for some time, and the diet advice out there is also very confusing, especially regarding fiber and pro-biotics. It seems that the drug, supplement, and diet treatments for SIBO only partially overlap and in fact diverge quite a bit for methane/constipation and hydrogen/diarrhea dominant forms, making things even more confusing.

I’m working with a functional MD in addition to a traditional GI specialist – I think the functional MD will be most helpful for the post-kill phase. I’ll share what I learn!

I was tested for sibo (breathe glucose test) and it came back unditerminable?! My base levels were high ( I got a last minute appt and had pizza the day before so this could have something to with it) but by the end of the test everything was negative and my levels only rose slighting after drinking the glucose. I have all the symptoms and I’m curious if trying the antibiotics are a good idea and will help. I’ve had some fodmaps in my diet but not many( mainly asparagus and garlic powder) and I’m still bloated after meals. Thanks!!!!

My son has been diagnosed with IBS with abdominal migraines and he has been put on amitrypitline and colestid. He has had endoscopy, colonoscopy and MRI to rule out crohns and ulcerative colitis. The endoscopy showed multiple small ulcers of his stomach and superior small intestine but nothing showed on the colonoscopy or MRI. I asked for a test to rule out SIBO because he was on amoxicillin for quite some time for acne treatment and I believe his flora is out of balance but the MD did not want to go that route. He did test him for H.pylori via stool sample and this also came back negative. A friend pointed me to the low FODMAP diet because our GI specialist didnt even suggest dietary changes. Although we have been On the low FODMAP diet for 3 weeks, there has been no change in his pain, or bowel habits. He has diarrhea at least 8 times per day with constant ache and the feeling of incomplete evacuation. I am at such a loss right now. It feels like nothing we do is helping. Despite having chronic diarrhea, he seems to be blowing up. In the last year he has gone from being underweight to obese. He has chronic fatigue and is now depressed because he has missed his entire senior year of high school. He has gone from a funny active teen to basically home bound. I dont know if I am asking for advice or a listening ear. I am just at a loss and have no idea what to do for my child. I’m an RN and feel like the medical community has failed us. Without the Dr doing a test for SIBO (which in all honesty might be the only thing he hasn’t been tested for) I feel like we are just stuck living this life of chronic pain and hopelessness.

Sorry to hear of your frustration. Definitely find a doctor who will test and take your concerns seriously. You can pay out of pocket for the test on your own, but it takes someone with knowledge to interpret. Try Dr. Will Cole – I love him.

I have sibo-d, hydrogen. My issue is 2-3 urgent diarrhea stools every morning for the past 7-10 years. It’s hard for me to even remember, anymore…. I had a small bowel follow through and my system is not slow. Are prokinetics still recommended for those with diarreah/loose stools? Also, what are the herbal protocol differences for those with hydrogen vs methane?

yes prokinetics post treatment are really dealing with the small intestine and D is usually something going on with the large. i.e. you can still have a SI motility issue and have D. Methane you will need to add Allicin for herbal or a second antibiotic.

Thanks for all the great information? Did you take both Fc cidal and dysbiocide two times a day every day for 6 weeks? I have tried so many different protocols and I am desperate to get rid of SIBO at this point 🙁

Hi, were you methane or hydrogen SIBO? After your 4 week kill phase were you still bloated? I tested positive for methane SIBO. Did 3 rounds of kill phase (first herbal with Allicin and Berberine, then Xifaxan with Metronidazole, and then another round of Allicin and Berberine). (Never tried oregano) Retested after first protocol and results of SIBO were minimal. But did the other 2 rounds because bloating was constant and never went away. Still bloated all the time, never goes away. 🙁 What reduced your bloating? The kill phase of herbals or the diet after? I follow the FODMAP diet but eat a lot of high fiber foods (Bananas; spinach;carrots etc). Wondering if high fiber diet is feeding the bacteria?

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I’m Phoebe: gluten-free chef, culinary instructor, Hashimoto’s advocate, & author. I’m obsessed with the sweet spot where health and hedonism intersect, in the kitchen and beyond. And I want to help you find it too. READ MORE ABOUT PHOEBE